Addiction deemed a brain disorder, not just bad behavior

WASHINGTON — Addiction is not only about willpower; it is a chronic brain disease, says a new definition aimed at helping families and their doctors better understand the challenges of treating it. “Addiction is about a lot more than people behaving badly,” said Dr. Michael M. Miller of the American Society for Addiction Medicine.

That is true whether it involves drugs and alcohol or gambling or compulsive eating, the doctors group said. And, like other chronic conditions such as heart disease or diabetes, treating addiction and preventing relapse is a long-term endeavor, the specialists concluded.

Addiction generally is described by its behavioral symptoms: the highs, the cravings and the things people will do to achieve one and avoid the other. The new definition does not disagree with the standard guide for diagnosis based on those symptoms.

Two decades of neuroscience has uncovered how addiction hijacks different parts of the brain, to explain what prompts such behavior and why it can be so hard to overcome. The society's policy statement, published on its Web site recently, is not a new direction as much as part of an effort to translate those findings to primary care doctors and the general public.

“The behavioral problem is a result of brain dysfunction,” agreed Dr. Nora Volkow, director of the National Institute on Drug Abuse.

She welcomed the statement as a way to help her own agency's work to spur more primary care physicians to screen their patients for signs of addiction. NIDA estimates that 23 million Americans need treatment for substance abuse but only about two million get that help. Trying to add compassion to the brain findings, NIDA even has made readings from Eugene O'Neill's Long Day's Journey into Night a part of meetings where primary care doctors learn about addiction.

Then there is the frustration of relapses, which doctors and families alike need to know are common for a chronic disease, Volkow said.

“You have family members that say, ‘OK, you've been to a detox program. How come you're taking drugs?’” she said. “The pathology in the brain persists for years after you've stopped taking the drug.”

Just what does happen in the brain? It is a complex interplay of emotional,

cognitive and behavioral networks.

Genetics play a role, meaning some people are more vulnerable to an addiction if they, say, experiment with drugs as a teenager or wind up

on potent prescription painkillers after an injury.

Age does, too. The frontal cortex helps put the brakes on unhealthy behavior, Volkow explained. It is where the brain's reasoning side connects to emotion-related areas. It is among the last neural regions to mature, one reason that it is harder for a teenager to withstand peer pressure to experiment with drugs.

Even if a person is not biologically vulnerable, to begin with, perhaps he or she tries alcohol or drugs to cope with a stressful or painful environment, Volkow said.

Whatever the reason, the brain's reward system can change as a chemical named dopamine conditions it to rituals and routines that are linked to getting something you have found pleasurable, whether it is a pack of cigarettes or a few drinks or even over-eating. When someone is truly addicted, that warped system keeps that person going back even after the brain gets so accustomed to the high that it is no longer pleasurable.

Patients still must choose to fight back and treat an addiction, said Miller, medical director of the Herrington Recovery Center at Rogers Memorial Hospital in Oconomowoc, Wisc.

Understanding some of the brain reactions at the root of the problem will “hopefully reduce some of the shame about some of these issues, hopefully reduce stigma,” he said.

While most of the neuroscience centers on drug and alcohol addiction, the society said that it is possible to become addicted to gambling, sex or food, although there is no good data on how often that happens. It is time for better study to find out, Miller said.

Volkow said intriguing research is underway to use those brain findings to develop better treatments, not just to block an addict's high temporarily but also to strengthen the underlying brain circuitry to fend off relapse.